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Physiotherapy and Occupational Therapy in the Acute
Medical Unit: Guidelines for Practice
N. Mearns, I. Duguid and the Physiotherapy and Occupational
Therapy Group
Society for Acute Medicine Conference
Imperial College London
October 2011
Revised and published: April 2015
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Physiotherapy and Occupational Therapy in the Acute Medical
Unit: Guidelines for Practice, 2015
Contents
1. Background, Purpose and Scope of Guidance
2. What is an Acute Medical Assessment Unit (AMU)?
3. The Key Roles of Physiotherapy and Occupational Therapy in
the AMU
4. Suggested Skills for AMU Physiotherapists and Occupational
Therapists
5. Algorithm of Physiotherapy and Occupational Therapy Process
in the
AMU
6. Documentation in the AMU
7. Activity Analysis
8. Appendices
a. Screening and Prioritising of Referrals
b. Subjective and Objective Components of Assessment
c. Discharge Support
9. References
10. Suggested Reading List
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Physiotherapy and Occupational Therapy in the Acute Medical
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1. Background, Purpose and Scope of Document
Acute Medical Units (AMUs) have become an increasingly common
part of the
assessment and decision-making pathway for acutely-presenting
medical
patients in NHS hospitals throughout the United Kingdom over the
past 15
years. Patients who present at AMUs are often older, frail and
with complex
medical and care needs. Consequently, many AMUs have developed
full
multidisciplinary team working, with the aim of achieving
timely, accurate and
holistic patient assessments at or very near the first point of
a patient’s
hospital attendance.
At time of writing no guidance for both physiotherapy (PT) and
occupational
therapy (OT) working within an AMU has been published or widely
circulated
through either printed or electronic media. Consequently, a
group of senior PT
and OT staff working in AMUs in the NHS convened under the
stewardship of
the Society for Acute Medicine (SAM) in London with the aim
of:
Sharing current established experience, working practices and
guidance
adopted in AMUs at local level;
Identifying core elements of effective organisational and
working
practice for PT and OT in the AMU that could be proposed as
common to
both professions;
Authoring and circulating through SAM a guidance document for PT
and
OT staff working in AMUs to reflect current best practice as
agreed by
this group.
Due to the collaborative nature of working between PT and OT,
and a
commonly-encountered overlap of the professional boundaries
experienced in
AMUs this document sets out the group’s agreed suggestions for
cross-
professional guidance to cover:
The purpose of an AMU and its normal functionality;
The most commonly-encountered roles and skill sets of AMU PT and
OT
staff;
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Physiotherapy and Occupational Therapy in the Acute Medical
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A common and clear pathway illustrating the place of PT and OT
in
assessment and destination identification for patients in the
AMU;
Indications of commonalities in documentation and patient
activity data
collection;
Other specific areas of screening, assessment and discharge of
the AMU
caseload considered useful to reflect current common practice in
PT and
OT.
This document’s scope is to suggest guidance for PT and OT in
the AMU.
Application of this guidance in the context of a therapist’s
specific
circumstances, expertise and service users is anticipated. It
does not replace
or supersede any area of formal uni-professional or regulatory
guidelines for PT
or OT. Rather, it indicates a starting point for best practice
for bi-professional
working where clear commonality of purpose and practice already
exists for
the delivery of best patient care in busy AMUs.
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Physiotherapy and Occupational Therapy in the Acute Medical
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2. What is an Acute Medical Unit?
The Royal College of Physicians (London) defines acute medicine
as:
“That part of general (internal) medicine concerned with the
immediate and
early specialist management of adult patients suffering from a
wide range of
medical conditions who present to, or from within hospitals
requiring urgent or
emergency care” (Royal College of Physicians, 2007).
The Society for Acute Medicine (SAM) defines the Acute Medical
Unit (AMU) as:
“The specialised area of an acute hospital where patients
suffering from acute
medical illness can be assessed and initially managed” (Society
for Acute
Medicine, 2010).
The AMU wards, or wards that sit in a broadly similar functional
position in a
hospital are often located close to the Emergency Department,
from where
their admissions often arrive. These are sometimes referred to
by a variety of
differing names and terms, such as Medical Assessment Units,
Assessment,
Clinical Decision-making Units, Assessment Areas and other terms
besides. For
clarity the term Acute Medical Unit is used throughout this
document.
Patients will generally stay in the AMU for 48 hours or less,
and after their
assessment a decision will be made for either discharged home,
or for transfer
to an in-patient acute medical ward or other relevant
speciality. Due to the
complexity, age and frailty of patients presenting to the AMU,
many units have
multi-professional teams consisting of nursing, medical,
pharmacy and AHP
staff to aid in-depth, timely and detailed patient assessment.
This should
facilitate accuracy of destination planning, and to enable safe
discharge for
the more complex patient. Some AMUs devolve discharge
decision-making to
the most relevant professional, dependent on the nature of the
patient’s
presentation: this is likely to include both the PT and OT
professions.
PT and OT frequently work in a collaborative manner in the AMU,
and by the
nature of the practical and functional breadth of these
profession’s practice
there may often be an overlap of scope of intervention during
patient
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assessment. This may lead to joint assessment and destination
decision-
making. Alternatively, it may be that either PT or OT
individually are best-
placed and skilled to lead the individual patient’s assessment,
dependent on
the nature of a patient’s presenting condition and surrounding
circumstances.
Consequently, and to aid efficient, thorough and timely patient
assessment it
is important that guidance for PT and OT is considered to avoid
repetitious
processes and practices in the AMU.
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Physiotherapy and Occupational Therapy in the Acute Medical
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3. The Key Roles of Physiotherapy and Occupational Therapy in
the AMU
The NHS is being organisationally challenged to respond to the
demands of an
ageing population. This demographic change suggests a rise of
35% in those
over 65 by 2028, increasing pressure on hospital capacity,
thereby potentially
reducing efficiency of care and quality of patient experience on
the current
background of financial constraints. As a result there is a need
to streamline
processes, reduce waste and provide more efficient and
patient-centred care
pathways that bridge the primary and secondary care systems.
AMUs are an
example of modifying pathways and practice to achieve these
ends. Full
multidisciplinary assessment of complex needs patients,
particularly older
people who are more likely to have long term conditions, is
essential if the
correct pathway from the AMU is to be attained, whether
discharge home or
speciality admission. Consequently, all AMUs should have a full
dedicated
multidisciplinary team (MDT) to achieve best outcome for the
acutely
presenting patient.
The PT and OT should be a core part of the AMU MDT, due to their
core
professional roles of assessment and rehabilitation of mobility
and function.
They will therefore be key in facilitating timely,
patient-focussed holistic
assessment and intervention for patients who are frail, elderly
and / or
complex in functional and social care needs. The unique
assessment skills that
PT and OT deliver should therefore aid rapid risk assessment,
support timely
decision-making and as appropriate early discharge planning.
By providing prompt expert, skilled and proficient assessment at
the Front Door
the therapists directly contribute to:
Improving the patient’s journey by either facilitating early
discharge or
providing early therapy goal-setting and intervention at the
start of a
hospital journey.
Reducing the length of stay of patients who do not require an
in-
patient hospital stay, particularly where community support can
assist
in achieving this goal.
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Rapid generation of onward referrals to intermediate care
services
thereby providing ongoing therapy intervention and enhanced
supported early discharge.
Promoting an approach to care that is holistic, team-based
with
patient-focussed outcomes, particularly for those with complex
needs.
Focussing on quality and value so that care and support for this
patient
group is safer, fair and person-centred, and delivered faster
and closer
to home where appropriate.
Promoting partnership working between health and social care
to
ensure best value is achieved by shifting the balance of care
to
community services.
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Physiotherapy and Occupational Therapy in the Acute Medical
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4. Suggested Skills for Physiotherapists and Occupational
Therapists in
the AMU
Depending on the size of the AMU the number of PT and OT staff
required will
vary. This section outlines suggestions of grades of staffing
and their roles the
AMU.
Band 7 or above:
This staff member will be the lead for their profession in the
AMU. In addition
to the skills, abilities and responsibilities expected of a band
7 PT / OT they
may also:
Be best placed to take role of specialist lead in acute medicine
for the
hospital
Demonstrate higher-level diagnostic and prognostic clinical
decision-
making abilities for acute medical patients
Lead and prioritise clinical service delivery for AMU on a daily
basis
Be responsible for acute medical therapy service development
and
evaluation
Band 6:
This qualified staff member is in a senior training role. They
will be key on a
day-to-day basis to clinical PT / OT service delivery in the
AMU, and will
deputise for the band 7 in their absence. In addition to the
skills, abilities and
responsibilities expected of a band 6 PT / OT clinical team
member they will
also:
Demonstrate sound diagnostic and prognostic clinical
decision-making
abilities for acute medical patients
Be able to prioritise clinical service delivery for AMU on a
daily basis,
and take lead of this role in their band 7’s absence
Assist in acute medical service development and evaluation
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Band 5:
This grade of qualified staff member is in a junior training
role. It is envisaged
that the AMU may have a band 5 staff member assisting with PT/OT
service
delivery. Due to the wide variety, complexity and acuity of
caseload in the
AMU their learning needs and potential skills gap must be
assessed and training
plans instituted as indicated. These staff should display the
general skills,
abilities and responsibilities expected of a band 5 PT / OT
clinical team
member. They will be supervised and supported by a band 6 / 7
staff member
of their own profession.
Band 2, 3 and 4:
These grades of staff will achieve workplace competency based
training and
potentially college-based vocational certificate training. These
assistant
practitioner PT / OT clinical team members will:
Work within the scope and practice of the grade and
competencies
achieved
Proactively gather information on acute patients to assist in
accurate
assessment and decision-making by the qualified therapists
Communicate in a timely, relevant and effective manner in the
AMU to
ensure that rapid decision-making is achieved in this
environment
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Physiotherapy and Occupational Therapy in the Acute Medical
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5. Physiotherapy and Occupational Therapy Process: An
Algorithm
See appendix a
See appendix a
See appendix b
Yes
Yes
No
No
Is patient PT/OT/MDT Fit
for discharge?
Screening for
Referrals
Prioritisation
Process
Clinical Assessment and Analysis
Admission to
Speciality
Discharge Home
+/- Support
PT / OT input (+/- other Rx)
in AMU
Suitable for
AMU stay?
See appendix c
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6. Documentation in the AMU
All PT and OT interventions must be recorded in accordance with
the Health
Professions Council standards (Health and Care Professions
Council, 2013), and
adhere to Chartered Society of Physiotherapy (The Chartered
Society of
Physiotherapy, 2013) or College of Occupational Therapists
(College of
Occupational Therapists, 2010) documentation guidance. Local
documentation
policies should be adhered to, and these must also allow
compliance with
regulatory and professional body guidance (Health and Care
Professions
Council, 2012).
During a patient’s short stay in the AMU a significant number of
assessment
outcomes and other results pertaining to the individual will
need to be
documented. To ensure clarity of communication in such a short
time period
multidisciplinary documentation in the AMU should be used and
kept centrally
in a unitary patient record (UPR). This may be in paper or
electronic form. This
will provide a logical, time-linear record of interventions, and
will aid
avoidance of unnecessary repetitious assessments. Clear and
accessible
recording of consent and capacity must be present in this
document.
Development of joint goal-setting and discharge planning should
also be
improved by use of the UPR format.
In the rapidly-changing environment of the AMU it is
particularly important
that documentation is written contemporaneously, preferably
after each
patient is assessed and treated. Writing clinical notes as a
batch at the end of
a shift will be likely to result in an entry being written out
with the short
timeline in which discharge or admit decisions are made, and
could result in
delay or confusion over patient placement decisions.
After initial assessment, a brief summary of PT and / or OT
findings, followed
by logically set goals and plan should be recorded. Goals must
be set after
discussion with both the patient and other relevant MDT members.
These goals
may be the primary determinants of whether a patient will
achieve discharge
from an AMU or if further rehabilitation is indicated. The use
of the “SOAP”
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Physiotherapy and Occupational Therapy in the Acute Medical
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model (subjective, objective, assessment / analysis, plan) of
documentation by
PT and OT should be applied in the AMU to structure continuation
notes and to
prompt continual evaluation of an individual case (Gateley &
Borcherding,
2012).
Assessment proformas may be of use for specific conditions, and
should be the
same format throughout a hospital site. For example, for stroke
patients in
AMU the same assessment proforma should be used as in the
hospital’s stroke
unit. These are therefore of particular benefit for patients who
will be
admitted to a speciality from the AMU. Functional scoring where
used should
be recorded in either the UPR or on an assessment proforma.
Scores typically
used in PT and / or OT assessment most frequently include
balance / mobility
scales such as the Elderly Mobility Scale (Smith, 1994), Borg
Balance Scale
(Berg, et al., 1992), Tinetti (Tinetti et al. 1986), Timed Up
and Go test
(Podsiadlo & Richardson, 1991) and 10 metre timed walk
(Peters, D. M., Fritz,
S. L. & Krotish, D. E., 2013). For more functional aspects
the FIM / FAM
(Functional Independence Measure / Functional Activities
Measure) (Turner-
Stokes et al. 1999) and Barthel (Wade et al. 1988) are commonly
used. The
practicalities of their institution as assessment items for
patients in AMU should
be left to individual units and hospitals to determine, and no
functional
outcome score specific to the AMU patient group has yet been
validated.
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Physiotherapy and Occupational Therapy in the Acute Medical
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7. Activity Analysis
A basic level of quantification of a service’s activity is
important, particularly
in the real-time, unscheduled environment that is the AMU. All
therapy
departments are likely to have a form of statistical collection
to identify
caseload, and local processes should be followed.
To identify the demands, capacity and impact of the PT/OT
service in the AMU
the schematic below demonstrates what factors could be
considered as a way
of quantifying these factors. Collection and audit of such data
may aid
demonstration of the value of PT/OT in the AMU. Routine
collection of
statistics should occur. The numbers of new referrals,
interventions, and
patient outcomes would give a routine baseline data set.
New Patient
New Patient
No assessment 20 to
no service capacity**
Discharged 20 to PT/OT
assessment
Inappropriate referral for PT/OT
Discharged from PT/OT; admitted medically
Admitted 20 to PT/OT
assessment
Overturn* d/c 20 to
PT/OT review
PT/OT Referrals
Assessment
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Notes:
Number of New Patients and subsequent classification of actions
as per
boxes should be components of routine activity analysis.
*: “Overturn” discharge patient is one whom medical staff
indicates
admission required; however through PT/OT intervention discharge
from
AMU is achieved.
**: Lack of capacity is wholly undesirable. Any lack requires
strategic /
managerial action.
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8. Appendices
a. Screening and Prioritisation of Referrals
b. Components of Assessment
c. Discharge Support
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a. Screening and Prioritisation of Referrals
In the busy environment of the AMU it is essential that patients
are referred to
the right member of the MDT in a timely manner to ensure
efficient care,
process and flow. The AMU should have a culture whereby any
member of the
MDT can refer a patient to another relevant team member; hence
knowledge
of each professional’s role is similarly prevalent throughout
the team. This
gives an effective and robust “push and pull” mechanism for
referrals.
AMUs will usually have an early-day consultant-led ward round, a
process that
may be repeated in the late afternoon. Alternatively there may
be continuous
presence of a senior medical team member on the unit operating
real-time
medical assessment and direction. It is not considered
time-effective for the
therapists to spend time on the ward rounds. Rather, the PT and
OT team
should have referral guidelines that are widely known throughout
the unit’s
MDT. Referrals should be gathered by an early-day screening
process by either
member of the therapy team. A combination of post-ward round
check and
real-time referrals from any other MDT member should ensure
capture of all
potential caseload. The PT/OT service must be flexible to both
accommodate
real-time referrals and to action these by prompt
assessment.
Once referrals are gathered prioritisation of caseload is
essential to ensure
that patients whom PT/OT can affect discharge for most readily
are seen first.
A scale of prioritisation will primarily consider the factor of
complexity of the
patient along with how their presenting acute medical problem
has affected
their function, and the likelihood of this illness being
resolved during a short
AMU stay. This requires a high level of clinical reasoning to
ensure treatment
order is logical.
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Physiotherapy and Occupational Therapy in the Acute Medical
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PT/OT Referrals
Ward-round Post-round check
PT/OT screening
round
Any MDT member
(any time)
Prioritisation Process
PT/OT Intervention
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Physiotherapy and Occupational Therapy in the Acute Medical
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b. Components of Assessment
The therapist must have a high-level working knowledge of how to
carry out
and interpret a comprehensive subjective and objective
assessment of many
differing patient presentations in the AMU. All items of these
assessment
components must be considered where relevant with appropriate
weight given
to those that are key for the individual patient. A thorough
comprehension of
the patient’s admission history and general medical status is
essential.
Subjective Components
Basic History: Functional history:
Presenting complaint Mobility (use of aids)
History of presenting complaint Falls history
Past medical history (including falls history) Equipment
(household /
Drug history adaptations)
Social history Continence history
Advocacy: Support:
Individual capacity Familial
Indicators of vulnerable adult status Formal / agencies
Safeguarding alerts Informal (e.g. friends /
neighbours)
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Objective Components
Baseline core assessment: Cognition:
Tone Mini-mental State Examination
Power Insight
Range of Motion Attention
Sensation, including pain Memory
Proprioception Retention
Coordination Self-awareness
Other components Planning and sequencing
(e.g. cranial nerves; vision) Mood
Respiratory assessment (where relevant)
Instruction-following
Functional and combined movement:
Balance Functional Activities:
Transfers (e.g. lie↔sit↔stand) Self-care and toileting
Gait Dressing
Exercise tolerance Kitchen assessment
Stair climbing Self-medication assessment
Falls risk assessment
(Note: Functional score may be useful)
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Falls Assessment
Prevention or reduction of the number of falls in older people
is best achieved
through a multifactorial risk assessment. The components of a
multi factorial
assessment and intervention programme are outlined in the
National Institute
for Clinical Excellence Clinical Guideline 21: “The Assessment
and Prevention
of Falls in Older People” 2004 (www.nice.org.uk); similarly
British Geriatric
Society / American Geriatric Society Clinical Practice
Guideline: “Prevention of
Falls in Older Persons” 2010. Local policies and guidelines
should also be
followed.
The following table gives a broad outline of factors that the
MDT should
consider in the context of falls risk reduction.
Falls History on admission Risk Factors Checklist on
Assessment
Number of falls in past month / 12
months;
Ability to get up from the fall;
Injuries sustained.
Mechanism of fall:
Loss of balance / dizziness
Collapse
Simple trip
Relevant medical history, for
example:
Neurological conditions; cardiac
conditions; arthritis; bone health
problems e.g. osteoporosis / fragility
fractures; pain.
Relevant pharmaceutical history:
Polypharmacy;
Vision:
Reported / observed difficulty seeing
objects / finding way around ward
Mobility:
Unsafe / impulsive / forgets mobility aid /
inappropriate aid
Transfers:
Appears unsafe / over-reaches /
impulsive
Behaviors:
Confusion / disorientation; difficulty
following instructions or non-compliant
Activities of Daily Living:
Risk-taking behaviours reported or
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Specific medications for example;
sedatives, antihypertensive, opiate
analgesics, diuretics.
Psychological status, for example:
Anxiety; reduced insight or
judgement; fear of falling.
Cognition:
Abbreviated Mental Test Score or Mini
Mental State Examination
Lifestyle factors:
Alcohol intake
Normal physical activity
Nutrition:
Underweight / low appetite
Continence:
Reported or known urgency / nocturia
/ accidents
observed
Footwear:
Unsafe footwear / inappropriate clothing
Environment:
Cluttered, stairs, trip hazards (e.g. rugs,
flexes, floor coverings, unsafe thresholds,
and pets.)
Poor lighting, low furniture.
No access to telephone or alarm call
system
Access to property, bins, garden, uneven
ground or footpaths
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Physiotherapy and Occupational Therapy in the Acute Medical
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Clinical Judgement and Reasoning
Clinical judgement is based on the therapist’s:
Interactive knowledge
Propositional knowledge, from an academic knowledge base
Professional knowledge, or knowledge through practice
Personal knowledge from individual reality and experience
Information gained from a full therapy assessment, inclusive of
MDT
findings
Clinical reasoning is a critical skill and central to the
therapists’ professional
autonomy. It is a complex process in a multidimensional context.
It underlies
the action taken in clinical situations and is based on facts,
principles and
experiences.
Clinical reasoning will involve any of the following:
Procedural/scientific reasoning
Interactive reasoning
Narrative reasoning
Conditional / predictive reasoning
Ethical reasoning
Pragmatic reasoning
Consent
It is a general legal and ethical principle that valid consent
must be obtained
before starting treatment or physical investigation, or
providing personal care
for a patient. This principle reflects the right of the patients
to determine
what happens to their own bodies, and is a fundamental part of
good practice.
A health professional who does not respect this principle may be
liable both to
legal action by the patient and action by their professional
body. Employing
bodies may also be liable for the actions of their staff.
(Health and Care
Professions Council, 2012)
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Physiotherapy and Occupational Therapy in the Acute Medical
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c. Discharge Support
Home Assessment / Discharge Visit:
Local Operational Home Assessment Guidelines should be adhered
to.
CPR Status must always be observed, and familiarisation of local
CPR guidelines
is essential.
In exceptional circumstances, a home assessment / discharge
visit may be
carried out if the following issues are identified:
Significant change in function/cognitive state
Require provision of equipment at time of discharge
Environmental/social concerns
Sensory impairment precludes accurate hospital-based
assessment
The purpose of the home assessment/discharge visit will be
explained to the
patient, carer/s and family. All involved will be made aware of
the date/time
of the assessment. All relevant persons involved, including the
patient will be
informed of the outcome of the visit and a copy of the home
assessment report
will be sent to all relevant persons. Should a discharge visit
prove unsuccessful
the patient will return to the hospital according to local
procedures.
Hospital / Community Interface
Discharges may be classified as follows:
Simple: Patients with stable circumstances, minimal social care
or
equipment provision needs or where there are no concerns from
care
providers and is discharged with pre existing services.
Moderate needs: patients with a change in health not
requiring
treatment within the hospital setting, but requiring short-term
social
care and equipment provision.
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Physiotherapy and Occupational Therapy in the Acute Medical
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Complex but rapid discharge: Patients with complex needs, but
pre-
existing arrangements meet the needs of patient and all care
providers,
including family. Patient is discharged with pre-existing or
minor
increase of services.
Complex and complicated discharge: This may include patient
with
multiple needs (e.g. frail elderly, terminal illness, palliative
care needs,
carer stress, housing issues, ongoing health needs), including
high level
of risks and anxiety surrounding potential discharge. There is a
need for
MDT co-ordination of services to ensure appropriate safe
discharge
planning.
Support services will vary with locale. The aim of these
services should be to
facilitate safe, effective and timely discharge. The following
are generic
examples of such services:
Intermediate care services:
Rapid response teams, community rehab teams, crisis
management
intervention teams
Uni-or Multiprofessionally-led services:
Day Hospital; Domiciliary OT /PT services; Specialty services
such as
Domiciliary COPD Physiotherapy services
Health and Social Care
Home care, Re-enablement services; Community Alarm Services;
Telecare services
Other services:
Day centres; Voluntary organisations
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(1992).
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Gateley, C.A and Borcherding (2012). Documentation manual for
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Peters, D. M., Fritz, S. L. & Krotish, D. E. (2013).
'Assessing the Reliability and
Validity of a Shorter Walk Test Compared With the 10-Meter Walk
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Physical Therapy, 36(1), pp. 24-30 [Online]. DOI:
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Podsiadlo, D., Richardson, S. (1991). The timed ‘Up and Go’
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